Acute Pulmonary Embolism Journal

8/7/2019 Acute Pulmonary Embolism Journal

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Supervisor :

Alex Kusanto M.DPresentant :

Alvin Pradipta Jennifer Kurniawan



� Shock/sustained hypotension to mild

dyspnea� may be asymptomatic



� male sex� advanced age�

cancer� major surgery� immobilization because of an acute

medical illness� trauma



� suspected in all patients :new or worsening dyspneachest painsustained hypotension

without an alternative obvious



� Severity of clinical presentationpatient·s condition (hemodynamically stable orunstable)



� hemodynamic stabilityclinical probability assessment,d-dimer testingmultidetector computed tomography (CT)

ventilation²perfusion scanning



� specificity of >> d-dimer level is reducedin

patients with cancerpregnant womenhospitalizedelderly patients



H D stable patientsLow/intermediate clin probNormal d-dimer testing

if anticoagulant treatment is not givenestimated 3-month risk of thromboembolism 0.14%

unnecessaryfurtherinvestigation



� If multidetector CT isnot availablerenal failure

allergy to contrast dye

� negative predictive value 97 %� diagnostic 30 to 50% of patients with

suspected pulmonary embolism

ventilation² perfusionscanning is analternative



� hemodynamically unstablemultidetector CT should be performed 97 %sensitivity for detecting emboli in the mainpulmonary arteries

� If not available echocardiography

should be performed to confirm thepresence of right ventricular dysfunction



� hemodynamically unstableShock , orSBP < 9 0 mm H gDrop in pressure of >40 mm H g>15 minutes (in the absence of new onsetarrhythmia, hypovolemia, and sepsis)

high clinical probabilityelevated d-dimer levelnegative findings on multidetector CT

venous ultrasonographyshould be considered



� should be done promptly� Based on clinical features and markers of

myocardial dysfunction or injury



� International Cooperative PulmonaryEmbolism Registry death rate

hemodynamically unstable 58%hemodynamically stable 15%



� ECG Right ventricular dysfunctionincreased mortality



� Acute pulmonary embolism requiresinitial shortterm therapy



� LMW H

Enoxaparin (at a dose of 1 mg/kgBW , twicedaily)tinzaparin (1 7 5 U/kg once daily)

� Fondaparinux once daily5 mg, BW< 50 kg7

.5 mg 50<BW<100 kg10 mg BW>100 kg



� Intravenous unfractionated heparininitial bolus dose (80 IU per kilogram or 5000 IU)followed by continuous infusion (usually starting

with 18 IU /kg/h)Target TT 1.5 to 2.5x normal value

�

LMWH &

F

ondaparinux excreted inkidneys



� Mortality 6 0% in untreated patients� Reduced < 30% with prompt treatment

� Major contraindications to thrombolytictherapy

intracranial disease

Uncontrolled hypertensionrecent major surgery or trauma (within the past 3

weeks)



� The risk of recurrent pulmonaryembolism

< 1% per year (receiving anticoagulant therapy)2 to 10% per year (after the discontinuation of such therapy)

Acute Pulmonary Embolism Journal

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